1. Pulmonary Edema vs Pneumonia Paramedic Program Sp2008

2. Acute Pulmonary Edema Clinical signs: shock, hypotension, congestive heart failure, acute pulmonary edema Most likely problem? Volume problemPump problemRate problem First-line Actions  Oxygen  Nitroglycerine SL  Furosemide 0.5 to 1mg/kg  Morphine IV 2 to10 mg Administer  Fluid Bradycardia? See algorithm Tachycardia? See algorithm Blood pressure Acute Pulmonary Edema, Hypotension, Shock

3. Let’s Review: Cardiac Output Cardiac Output  5000-6000 ml/min. HR or SV = CO HR or SV = CO Sympathetic effects: Sympathetic effects:  HR and SV Parasympathetic: Parasympathetic:  Slows HR  Little effect on SV

4. Review: SV = pressure in ventricle SV = pressure in ventricle  Frank Starling effect Peripheral vascular constriction increases venous return Peripheral vascular constriction increases venous return  = Increased RV output. Vasodilation of arteries decreases PVR and diastolic pressure Vasodilation of arteries decreases PVR and diastolic pressure  = Decreased CO.

5. Vital Signs Normal B/P is 120/70 mmHg Normal B/P is 120/70 mmHg  Increases with age  General:  Systolic – 100 + age up to 140  At age 50: usually 140 mmHg  Increases 1 mmHg/yr after 50.

6. CHF Causes Normal heart muscle AMI Left ventricular enlargement

7. Abnormal Cardiac Function Dispatched as: Dispatched as:  Man down  Chest pain  Heart attack  SOB  Fainted  Dizzy  Passed out  Choking  Stroke  DFO  DRT

8. Initial Assessment: Brief History Brief History  Onset  Provoking factors  Quality  Radiation  Severity  Time  BP changes

9. Initial Assessment  Meds  Cardiac rhythm  Abnormal breathing  Edema  Rales  Changes in skin color and moisture

10. Right and Left Heart Failure Right Heart Failure Causes Causes  COPD  Left heart failure Progression Progression  Right ventricle cannot eject all of the blood  Fluid/pressure backs up  Right atrium  Venous system  Pedal edema, JVD Left Heart Failure Causes  High afterload Progression  Left ventricle cannot eject all of the blood  Fluid/pressure backs up  Left atrium  Lung tissue  Alveoli  Pulmonary edema

11. Acute Left Ventricular Failure Acute LVF from heart disease: Acute LVF from heart disease:  #1 cause of heart failure.  Assume the worst, hope for best Pt. with CAD w/ hx of MI(new or old) Pt. with CAD w/ hx of MI(new or old)  May develop LVF. Frequently LVF is only manifestation of AMI. Frequently LVF is only manifestation of AMI.

12. LVF Common causes Common causes  Systemic HTN  Afterload  Coronary artery disease  Arteriosclerosis/atherosclerosis  Ischemia  Local/temporary occlusion

13. LVF Common Causes Common Causes  Infarction  Permanent, necrosis  Significant Sized Infarct Decrease effective wall motionDecrease effective wall motion Decreased stroke volumeDecreased stroke volume  Cardiomyopathy Alcoholism one of main causesAlcoholism one of main causes

14. LVF Other Causes Other Causes  Volume overload  Bag of Potato Chips  Severe anemia  Hypoxemia

15. LVF and Pulmonary Edema Incidence of CHF doubles per decade of life Incidence of CHF doubles per decade of life > 3 million in US; > 400,000 new diagnoses/yr > 3 million in US; > 400,000 new diagnoses/yr 5 yr mortality rate /p dx; 5 yr mortality rate /p dx;  60% in men  43% in women

16. Basically this happens Forward or backward ventricular flow. Forward or backward ventricular flow.  Forward – (LVF) – reduced flow into aorta and systemic circulation  Backward – elevated systemic venous pressure

17. NY Heart Association’s classification of CHF Class I Class I  Not limited by symptoms Class II Class II  Fatigue, dyspnea, other sx with ordinary physical activity Class III Class III  Marked limitation with normal activity Class IV Class IV  Symptoms at rest or with any activity

18. CHF Acute CHF Acute CHF  Rapid Chronic CHF Chronic CHF  Slow  Midnight shoppers

19. Pulmonary edema also results from:  CVA  Pulmonary embolism  Infection - Sepsis  Allergy  Inhalation of fumes  Narcotic abuse  Especially Inhaled (Heroin)  Altitude sickness.

20. Acute Findings History History  Recent change in sleep patterns  More frequent trips to the bathroom  Need to sleep on more pillows at night  Recent move to the recliner at nights  New episodes of PND Paroxysmal Nocturnal DyspneaParoxysmal Nocturnal Dyspnea Sudden awakening with acute shortness of breathSudden awakening with acute shortness of breath Relieved after standing or sitting upright for a period of time (Midnight Walmart shoppers)Relieved after standing or sitting upright for a period of time (Midnight Walmart shoppers)

21. Acute Findings History History  Is more nitroglycerin needed to stop the episodes of chest pain?  Have nitroglycerin or oxygen doses increased incrementally in the last few days?

22. Acute Findings – Critical Patient General impression/initial assessment General impression/initial assessment  Labored respirations  Audible sounds  Tripod position  Frothy sputum  Retraction of chest muscles

23. Acute Findings – Critical Patient General impression/initial assessment General impression/initial assessment  Lung sounds  Wheezing, crackles  Middle-to-upper lung fields  Diaphoresis, change in skin color  Severe anxiety or restlessness  Tachycardia or bradycardia  Severe hypertension may be present

24. Tachypnea Tachypnea Orthopnea Orthopnea Paroxysmal Nocturnal Dyspnea Paroxysmal Nocturnal Dyspnea  Elevation of pulmonary venous & cap pressures  Wakening from sleep Pulmonary Edema – S/S

25. Pulmonary Edema – more S/S Noisy Labored Breathing Noisy Labored Breathing Fine crackles/Rales Fine crackles/Rales Wheezes Wheezes  Reflex airway spasm  “Cardiac asthma” Coarse crackles/Rhonchi (larger airways) Coarse crackles/Rhonchi (larger airways) Coughing Blood Tinged Sputum  Pink Frothy

26. Normal chest xray

28. So, What to do? Decide – Sick/NotSick? Decide – Sick/NotSick? Vitals Vitals Look Look  Skin – wet/dry, color, temp  JVD  Peripheral edema  Subtle signs

29. Look Listen Listen  Breath sounds  Pulse x 6  Skin

30. Treatment of RVF & LVF CHF a circumstance not CHF a circumstance not a Dx Treatment objectives Treatment objectives  Decrease myocardial:  Workload  Oxygen demand  Reduce fluid retention

31. Treatment Decrease Workload Decrease Workload  No Physical activity  Sitting upright  Oxygen  Pt may tolerate BVM  CPAP – studies are promising  Decreases preload and afterload in CHF  Improves lung compliance  BiPAP  CPAP but also delivers higher pressure during inspiration

32. Treatment OMI OMI  Oxygen, Monitor, IV MONA - if appropriate MONA - if appropriate  Morphine, Oxygen, Nitro, ASA (Not in that order) Don’t let patient walk! Don’t let patient walk! Position of comfort Position of comfort Reassure Reassure Positive Pressure Ventilations if necessary Positive Pressure Ventilations if necessary

33. Treatment Vasodilatory Therapy (Nitrates) Vasodilatory Therapy (Nitrates)  AMI reperfusion  Container expansion reduces preload Morphine Morphine Reduce Fluid Retention Reduce Fluid Retention  Diuretics  Lasix  Bumex

34. Differential Diagnosis Pneumonia Pneumonia Herpes Zoster Herpes Zoster Pleurisy Pleurisy COPD COPD Rib fracture Rib fracture Asthma Asthma Angina Angina MI MI Pneumothorax Pneumothorax Pancreatitis Pancreatitis Hepatitis Hepatitis Salicylate OD Salicylate OD Bronchitis Hyperventilation Lung carcinoma Sepsis TB Muscle pain Costochondritis Pericarditis CHF Percardial tamponade

35. Pneumonia The statistics Community acquired pneumonia Community acquired pneumonia 4.5 million cases annually in US 4.5 million cases annually in US  Winter months/Colder climates  More men than women  20% require hospitalization 6 th leading cause of death 6 th leading cause of death Most common infectious cause of death Most common infectious cause of death

36. Viral Viral  Upper and lower respiratory infections Untreated, mortality > 30 % Untreated, mortality > 30 %  37.7% in elder > 80 y/o Sudden onset of S/S & rapid progression suggest bacterial pneumonia Sudden onset of S/S & rapid progression suggest bacterial pneumonia

37. S/S Productive cough Productive cough  Sputum may be  Green  Rust-colored  Current jelly  Foul smelling Rigor or shaking chills Rigor or shaking chills Headache Malaise N/V/D Exertional dypsnea Pleuritic chest pain, friction rub Abdominal pain

38. S/S, cont. Fever Fever Tachypnea Tachypnea Tachycardia Tachycardia Cyanosis Cyanosis Wheezes, coarse & fine crackles Wheezes, coarse & fine crackles Anorexia & weight loss Anorexia & weight loss Dullness to percussion Altered mentation

39. typical pneumonia generally resides in the nasopharynx carried asymptomatically in approximately 50% of healthy individuals nosocomial pneumonia aspiration or inhalation; ~ 45% of healthy people aspirate during sleep; even higher in severely ill patients; often bilateral

40. Pneumocystis carinii pneumonia Bacterial pneumonia Viral pneumonia

42. Host Factors DKA DKA Alcoholism Alcoholism Sickle Cell Sickle Cell HIV HIV

43. So – how do we tell the difference????? CHF/Pulmonary Edema CHF/Pulmonary Edema  Wheezes, fine & course crackles  Cardiac history  Productive cough  ↑ dyspnea suddenly  JVD  Cyanosis  Finger clubbing  Prolonged expiratory phase  Tachypnea, tachycardia  Accessory muscle use  Paroxysmal nocturnal dyspnea Pneumonia  Wheezes, Course & fine crackles  Febrile, chills  Productive cough  Hx URI, OM, Conjunctivitis  Tachypnea, tachycardia  Cyanosis  H/A  Malaise  Abdominal distention  N/V/D

44. Pneumonia Pulm. Edema COPD/Asthma HistoryN/A HTN, Heart problems Lung problems Dyspnea Orthopnea potential Orthopnea Chronic dyspnea Recent Hx Fever, malaise, etc. Acute Wt. gain Edema in legs Gradual Wt. loss Cough Productive, thick, green Foamy sputum Productive (bronchitis) OnsetGradualRapidGradual BPNormalHighNormal Meds Antibiotics, cold medicines Digoxin, antiHTN, diuretics BronchodilatorsSteroids Treatment Oxygen, Med- neb, IV fluids High flow O2 NTG, Lasix, MS Oxygen, Med-neb Rx

45. Treatment summary Pulmonary Edema Pulmonary Edema  OMI  MONA if approp.  Position of comfort  Nitroglycerin 0.4 mg SL per protocol  Morphine 2-10 mg Lasix per protocol (commonly 40 mg)  CPAP if available Pneumonia  OMI  Limit IV fluids if hx of cardiac disease  CPAP if available

46. Medications for Pulmonary edema Nitroglycerine Nitroglycerine Morphine Morphine Lasix Lasix

47. Nitroglycerin Drug Class: Nitrate vasodilator Relieves myocardial workload Dilates the arterial and venous systems Dilates the arterial and venous systems  Reduces preload to the already overworked ventricles  Reduces blood pressure to reduce afterload Allows pressure and fluid to move into the venous system Allows pressure and fluid to move into the venous system Sublingual doses start at 0.4mg Sublingual doses start at 0.4mg

48. Morphine Sulfate Drug Class: Narcotic Analgesic Relieves myocardial workload as well Dilates the venous and arterial systems Dilates the venous and arterial systems  Reduces preload and afterload  May cause hypotension

49. Morphine Sulfate: Other Actions Mechanism of action Mechanism of action  Binds to opiate receptors throughout the CNS  Slows respiratory rate at the medulla  Stimulates the nausea center in the brain

50. Morphine Sulfate Administration Administration  2-4mg over 1-2 minutes, every 5 minutes (usual max dose 10 mg)

51. Furosemide Class: Loop Diuretic Class: Loop Diuretic Moves sodium out of the blood vessels early in the kidney Moves sodium out of the blood vessels early in the kidney  Water follows sodium into the kidney tubules  The site pulls out potassium as well Provides some vasodilation within 5 min. Provides some vasodilation within 5 min. Diuresis within 20-30 min. Diuresis within 20-30 min.

52. Furosemide Reduces preload Reduces preload  vasodilation  Pulls the extra fluid out of the circulation  Keeps fluid moving out of the kidney Medication effects Medication effects  Effects seen within 5-15 minutes of administration  Peaks in 30 minutes after administration

53. Furosemide Administration 20-40mg IVP over 1-2 minutes 20-40mg IVP over 1-2 minutes Double the dose if the patient is currently taking a diuretic Double the dose if the patient is currently taking a diuretic Relief of symptoms should begin within 5 minutes Relief of symptoms should begin within 5 minutes  If no relief, consider BVM

54. SHOPS drugs – CHF patients Street drugs Street drugs Herbal drugs Herbal drugs OTC drugs OTC drugs Prescription drugs Prescription drugs Sexual enhancement Sexual enhancement

55. Street drugs may contribute to CHF Cocaine Cocaine Meth Meth Inhaled solvents Inhaled solvents PCP PCP

56. Herbal remedies Possibly helps Possibly helps  High-rite  Aqua-rite  L-arginine  Magnesium  Berberine Possibly hurts  St. Johns Wort  Ephedra  Ginko Biloba  Kava Kava  Licorice  Ginseng  Aconite  Alisma plantago  Bearberry Buchu  Couch grass  Dandelion  Horsetail rush  Juniper

57. Over-the-counter drugs (OTC) Cold Medications Cold Medications

58. Common Prescription medication for CHF/Pulmonary Edema (Calcium channel blocker) (Calcium channel blocker)  Amiodarone  Norvasc Ace Inhibitors Ace Inhibitors  Vasotec  Capoten  Lotensin  Accupril  Altace Angiotension II receptor blockers  Cozaar  Avapro Beta Blockers  Coreg

59. Sexual enhancement drugs Viagra Viagra  24 hours Cialis Cialis  36 hours Levitra Levitra  unknown